“The Terrible 2s” (or 3s) is a common life stage for almost every child. Mood swings during puberty and adolescence are normal, too. But is there ever a time when a parent should be concerned that something more serious is going on?

If your child’s tantrums or mood swings seem much more severe and frequent than they should, it could be time to consult a mental health professional.

According to the International Bipolar Foundation (IBF), bipolar disorder “causes unusual shifts in a person’s mood, energy and ability to function.” “Unusual” means that the symptoms are much more severe than the regular ups-and-downs that most people experience. A person with bipolar disorder experiences very dramatic mood swings, from very high “highs” (mania) to very low “lows” (depression).

Children can develop bipolar disorder—sometimes referred to as pediatric bipolar disorder (BPD)—although most people who have bipolar disorder develop it in their late teens or in early adulthood, according to the National Institute of Mental Health. Diagnosis of this particular brain disorder can be challenging, however. It can mimic other conditions. And it’s not uncommon for someone with bipolar to have another diagnosis, too, such as ADHD or an anxiety disorder.

If you are concerned that your child might have bipolar disorder, schedule an appointment with your the pediatrician, who may then direct you to a child psychiatrist. An appropriate diagnosis is necessary before any treatment can begin.

“It’s a subjective diagnosis based on a plethora of symptoms that you’re kind of checking off the boxes,” explains Walker.

That includes examining past behaviors and a number of other factors, including family history. If there is a history of bipolar disorder in the family, your child could be at elevated risk for developing this illness, too.

“It’s a known risk factor,” says Dr. Ken Duckworth, medical director for the National Alliance on Mental Illness. “You don’t have to have a family history. It just increases your risk.”

Because of the challenges, Duckworth notes that he considers himself “conservative” when it comes to making a diagnosis of bipolar disorder in a child. But it’s a delicate balance because he does not want to underplay the matter, either. For those reasons, he emphasizes the importance of getting a very thorough patient history and examination that includes looking at the child’s sleep patterns, exercise routines and stress levels.

It’s even trickier with teenagers, Walker says. “You don’t know if you’re really dealing with a lot of hormonal stuff and possible drug and alcohol use,” she says, “or if they are bipolar and they’re quelling the symptoms by using drugs and alcohol, which is very common.”

Treating Bipolar in Children

Having a good diagnosis is critical, experts say, because it will affect the course of treatment that a child receives. If diagnosis can be challenging, treatment can be challenging, too.

There are two main components to treatment: psychotherapy, or “talk therapy,” and medication. Many experts choose to use a combination of both to manage a child’s symptoms, along with other coping strategies. Some youth respond to certain medications better than others, so finding the right medication can be a matter of trying until finding one—and the right dose—that works.

The mood stabilizer lithium, which treats the manic symptoms of bipolar disorder in children ages 12 and older

The atypical antipsychotic medications risperidone (Risperdal), quetiapine (Seroquel), and aripiprazole (Abilify), which have been approved for use in children ages 10-17

Another atypical antipsychotic called olanzapine (Zyprexa) for adolescents ages 13 and older

Some doctors choose to prescribe certain medications “off label” in an attempt to find the most effective treatment or management of a young person’s symptoms.

“It’s not just a one-stop treatment plan,” Walker explains, noting that medication, talk therapy, a good sleep hygiene program and a good diet may all need to be used in concert to achieve the best results.

Long-term Prognosis

The IBF states that people whose illness is effectively treated can live very productive lives, but the key is effective treatment.

However, less is known at this point about the long-term prognosis for children who are diagnosed with bipolar disorder because there has not been as much research on them. And some of the research done in the 1990s only used very loose diagnostic criteria, notes psychiatrist Dr. Thomas Jensen.

“We do not know a lot about what happens to bipolar children as they grow up,” says Jensen, IBF’s medical director. “My experience in treating these kids over the past 20 years is that a small number of them seem to almost outgrow it. Most continue to need medications long-term, often requiring med changes in adolescence.”

The NIMH notes that treatment is more effective when it is ongoing, not off-and-on.

But the first step is getting the right diagnosis. So if you’re concerned, the best way to proceed is to consult a professional.